Provider Demographics
NPI:1073103149
Name:BOS, KENNETH JAMES (PTA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAMES
Last Name:BOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11463 W PROGRESS PL
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-1683
Mailing Address - Country:US
Mailing Address - Phone:303-903-3603
Mailing Address - Fax:
Practice Address - Street 1:10001 S OSWEGO ST
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-3786
Practice Address - Country:US
Practice Address - Phone:720-928-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0014655225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTA.0014655OtherDORA - COLORADO